Prior Authorization Specialist


POSITION:  Prior Authorization Specialist

DEPARTMENT: Quality Enhancement

REPORTS TO: Health Information Manager

DIRECT REPORTS: None

FLSA STATUS: Non-Exempt

CORE VALUES

The core values of Community Health Center of Southeast Kansas, Inc. (CHC/SEK) are dignity and stewardship.  Each staff member is expected to perform their job duties in a way that preserves dignity for our patients and maintains good stewardship of CHC/SEK’s resources.

GENERAL DESCRIPTION

The Prior Authorization Specialist will obtain prior authorizations for diagnostic imaging, cardiac imaging, prescription medications including hospital administered IV infusions, Veterans Administration authorizations, some durable medical equipment, and referral authorizations for some specialist appointments. This position will secure the prior authorization and notify the rendering party in the timeliest manner possible so our patient receives the services needed with the least delay.

ESSENTIAL DUTIES

  1. Receive request for prior authorizations through the electronic health record (EHR) and/or via phone or fax and ensure that they are properly and closely monitored.
  2. Process referrals and submit medical records to insurance carriers to expedite prior authorization processes.
  3. Manage correspondence with insurance companies, physicians, specialist and patients as needed, including documenting in the EHR as appropriate.
  4. Assist with medical necessity documentation to expedite approvals and ensure that appropriate follow-up is performed.
  5. Review accuracy and completeness of information requested and ensure that all supporting documents are present.
  6. Review denials and follow up with provider to obtain medically necessary information to submit an appeal of the denial.
  7. Prioritize the incoming authorizations by level of urgency to the patient
  8. Secure patient information in accordance with CHCSEK policy/procedures.
  9. Other duties as assigned.

QUALIFICATIONS AND SKILLS

  1. High school diploma or equivalent.
  2. Previous experience in a clinic setting preferred.
  3. Knowledge of insurance process and medical terminology preferred.

POSITION:  Prior Authorization Specialist

DEPARTMENT: Administration

REPORTS TO: Director of Operations

KNOWLEDGE, SKILLS AND ABILITIES

  1. Social and cultural sensitivity appropriate to ethnically and economically diverse patient-and employee-base
  2. Communicates through appropriate channels. Use proper chain of command for patient complaints.
  3. Ability to handle emergency situations calmly and effectively.
  4. Must be computer literate and able to navigate through the Electronic Health Record.
  5. Must be able to maintain good inter-personal relationship with co-workers and other members of the health care team and the organization.
  6. Provide customer service in accordance to the organization’s mission.
  7. Be courteous and respectful when interacting with patients and family members.
  8. Maintain patient confidentiality in accordance to organization’s policy and procedure and HIPAA requirements.

WORKING CONDITIONS

While performing the duties of this Job, the employee is regularly required to sit; use hands to finger, handle, or feel; reach with hands and arms and talk or hear. The employee is occasionally required to stand. The employee is occasionally required to walk.  The employee must occasionally lift and /or move up to 10 pounds.  Specific vision abilities required by this job include close vision, color vision, peripheral vision, depth perception and ability to adjust focus. Computer work is frequent. Good lighting and comfortable temperature of ventilation at all times.